Differences in the psychological preparedness of emergency nurses for caring for victims of violence against women according to nurse gender: a nationwide cross-sectional questionnaire survey in Japan

Article information

Acute Crit Care. 2024;39(4):630-639

Publication date (electronic) : 2024 October 23

doi : https://doi.org/10.4266/acc.2024.00654

Department of Adult and Geriatric Nursing, Faculty of Health Sciences, Shinshu University School of Medicine, Nagano, Japan

Corresponding author: Akane Kato Department of Adult and Geriatric Nursing, Faculty of Health Sciences, Shinshu University School of Medicine, 3-1-1 Asahi Matsumoto, Nagano 390-8621, Japan Tel: +81-263-37-2374 Fax: +81-263-37-2374 E-mail: akane@shinshu-u.ac.jp

Received 2024 April 22; Revised 2024 August 5; Accepted 2024 August 16.

Abstract

Background

With the increasing incidence of violence against women (VAW), emergency department (ED) nurses should be trained to respond appropriately to victims of VAW (VVAW). However, the psychological preparedness of nurses caring for VVAW and its relationship to nurse gender remains unclear in Japan.

Methods

A nationwide self-administered questionnaire survey was conducted among 430 randomly selected certified emergency nurses. The questionnaire was a Japanese translation of the evaluation tools from the World Health Organization (WHO) curriculum "Caring for women subjected to violence: a WHO curriculum for training healthcare providers."

Results

The final sample included 104 participants, and the effective response rate was 24.2%. More than 60% of nurses had experience in caring for VVAW; however, only 10% had received training concerning VAW. The mean number of VVAW cared for by these nurses was 6.2 (standard deviation, 6.1) with no significant difference in nurse gender (P=0.52, effect size [ES]=0.09). Male nurses had a higher mean score of psychological preparedness than female nurses (22.6 vs. 20.4; P=0.03, ES=0.22); moreover, female nurses scored lower than male nurses on all items of the psychological preparedness evaluation. Less than half of the participants reported having institutional support systems.

Conclusions

Establishing an education program for all emergency nurses, providing support to ensure the psychological preparedness of female emergency nurses, and ensuring improvement of facilities nationwide are essential for enhancing nursing care for VVAW in Japanese EDs.

Keywords: domestic violence; emergency nursing; gender-based violence; intimate partner violence; victim

INTRODUCTION

The global landscape underwent a significant transformation, impacting not only healthcare but also distribution and economics, because of the coronavirus disease 2019 (COVID-19) outbreak. Unprecedented measures against infectious diseases, such as lockdown, stay-at-home orders, and social distancing, were implemented [1]. These restrictions on all interactions with other individuals resulted in social isolation, economic deprivation, disruption of welfare services, and increased risk of domestic violence against women (VAW) and children [2]. Moreover, this impact is reflected in the healthcare-seeking behavior. Medical institution visits by domestic violence victims decreased by approximately 30% during the COVID-19 pandemic [3]. In Japan, the number of consultations on violence from intimate partners increased from 106,110 in 2017 to 122,211 in 2022, and the ratio of male to female counselors was 1:37 [4], indicating that the overwhelming majority of domestic violence victims were women. Furthermore, most victims of various forms of violence, except for homicide, are women and girls [5,6]. VAW, including domestic violence and rape, is a serious global concern and major public health issue [7]; countries worldwide are focusing on preventive and control measures for VAW [8]. Although the number of cases is lower than that reported in other countries, the number of arrests for rape and sexual violence in Japan in 2023 was approximately 6,400 [9,10]. Thus, the Japanese Cabinet Office designated the years 2020 to 2022 as the "strengthening measures against sexual crimes and violence" period and further extended this period from 2023 to 2026 [11], thereby highlighting sexual violence as a serious ongoing social problem in Japan.

Based on previous studies in other countries, victims of various forms of violence visit emergency departments (EDs) following assaults [12-15]. Although these victims of various forms violence have specific needs [16,17], these victims share the common experience of having undergone a fearful and painful incident. These incidents have long-term impacts on the victims’ physical, psychological, and social well-being. These impacts can include post-traumatic stress disorder [18,19]. Therefore, identification of the victims and institution of appropriate immediate intervention by medical staff are necessary following the injury. In certain cases, such as facial injuries, the emergency medical staff can quickly identify individuals as victims of violence upon initial contact [20]. However, identifying the source of the symptoms resulting from violence is challenging owing to its inherent complexity [21]. Furthermore, educational and training opportunities related to caring for victims of various forms of violence both during university studies and after graduation are lacking [22-24]. Hence, the medical care provided to victims of various forms of violence in EDs is insufficient [25-27]. Thus, the World Health Organization (WHO) emphasizes that professionals should be appropriately sensitized to issues of abuse, treatment of women with respect, maintaining confidentiality, and avoiding reinforcing women’s feelings of stigma or self-blame. These are in addition to being prepared to provide appropriate care referral as needed [28].

Hence, the Japanese Association for Acute Medicine has established a "Special Committee on Sexual Crime Victim Support" and is actively engaged in strengthening measures in response [29]. However, the Japanese Association for Emergency Nursing has not been able to establish appropriate educational programs and committees. To improve care for victims of VAW (VVAW) by emergency nurses in Japan, clarifying the current state of emergency nursing care for VVAW is necessary. This study aimed to assess the educational training provided to manage cases of VAW, the degree of the nurses' psychological preparedness for caring for VVAW, and the existence and role of institutional support systems. Additionally, because of the strong association of VAW with socially and culturally constructed fixed gender roles, norms, and unequal power dynamics [30], this study also tested the following hypotheses: (1) significant differences exist in the experiences and psychological preparedness to care for VVAW based on nurse gender, and (2) significant differences exist in institutional support systems based on institutional characteristics.

MATERIALS AND METHODS

All the procedures were approved by the Institutional Review Board of Shinshu University (No. 4798). The survey included a description of the purpose of the study to inform participants, the data collection procedure, and the rights of the participants in this study. Participants were required to agree in writing before completing the questionnaire. Additionally, to ensure participants’ safety, a document cautioning that “this survey was about violence victimization” was attached to the questionnaire because the participants may have also been VVAW.

Study Design

The flow of this study is shown in Figure 1. This nationwide cross-sectional study was a quantitative descriptive analytic study that was conducted using an anonymous self-administered questionnaire survey. The survey was conducted from March 20 to April 20, 2022. To enhance the response rate, we remailed a copy of the questionnaire to all sampled certified emergency nurses (CENs) a month after the initial distribution.

Figure 1.

Study flow diagram. CEN: certified emergency nurses.

Participant Sampling

This study included 430 CENs who were randomly selected from a pool of 968 CENs listed on the website of the Japanese Nurses Association (https://nintei.nurse.or.jp/certification/General/GCPP01LS/GCPP01LS.aspx). CENs receive special education and training in emergency nursing and are responsible for improving the quality of emergency nursing care in their institutions. As the provision of care for VVAW is not widespread in Japanese nursing, we targeted CENs because of their important role in enhancing emergency nursing care. The sample size was calculated using G*Power ver. 3.1 with these parameters: allowable error, 0.05; answer ratio, 0.5; confidence interval, 95% (Z value 1.96); and estimated response rate, 0.5.

Questionnaire

The draft questionnaire, “Caring for women subjected to violence: a WHO curriculum for training healthcare providers: evaluation of tools for pretraining assessment,” has 18 categories and was translated into Japanese by the researcher. These categories include knowledge, perspective psychological preparedness, and system support [31]. English-Japanese bilingual experts subsequently reviewed the translated text and made some minor revisions. Two questions were removed from the original WHO assessment tools as their content seemed redundant when translated into Japanese. Five multi-disciplinary specialists, including emergency physicians, nurses, and emergency nursing researchers, who were recruited using snowball sampling confirmed the validity of the contents.

Experience in Providing Care for VVAW

Participants were asked for information on their experience in providing care for VVAW and the number of VVAW cared for.

Psychological Preparedness for Caring for VVAW

This category consisted of nine items assessing the degree of psychological preparedness to care for VVAW. Items used for assessment included "identify a woman who is or has been subjected to intimate partner violence by the signs and symptoms she reports" and "ask a female patient about whether she has experienced intimate partner violence." Responses were rated on a scale of 1 (“not at all prepared”) to 4 (“quite well prepared”). If the participants were unsure of an answer, their instructions were to answer “neither (0 points).” The sum of scores for nine items (ranging from 0–36 points) was used to calculate the psychological preparedness to care for VVAW. The reliability of each item and total score was tested using Cronbach’s alpha coefficient. The range of Cronbach’s alpha coefficients for each item was 0.873–0.895, and the Cronbach’s alpha coefficient for psychological preparedness to care for VVAW was 0.897 in this study. In general, a Cronbach’s alpha coefficient of ≥0.7 is con-sidered a reasonable goal [32].

Institutional Support Systems

Participants were asked about resources and institutional support for ensuring efficient nursing care for VVAW in four items that included “I can readily look up information (e.g., either a guide or standard operating procedure on how to manage cases of intimate partner violence or sexual violence).” Participants were asked to answer with "yes" or "no" to statements such as “I have a private space in the facility where I can talk to the woman confidentially about abuse.” In addition, two items in this category were removed from the original WHO assessment tools upon validation.

Participant Background

The questionnaire in this study included questions about the participants' sociodemographic background, such as gender, age, marital status, number of children, years of experience in nursing and emergency nursing, and types of EDs in which the participants were currently working (advanced ED, ED, local emergency ward, and others). Additionally, experience with education concerning care for VVAW was requested.

Analysis

First, descriptive analysis was conducted on the participants’ demographic and institutional characteristics, experience in caring for VVAW, educational training on caring for VVAW, psychological preparedness to care for VVAW, record of providing nursing care for VVAW, and availability of institutional support systems. Chi-square test and Student’s t-test were conducted to assess the differences between the experiences for caring for VVAW and the number of VVAW cared for according to the nurse's gender. Differences in the total score and each item score of psychological preparedness to care for VVAW based on gender were subsequently assessed using Welch’s analysis or t-test. Finally, Fisher's exact test was used to assess the difference between the availability of institutional support systems and the number of hospital beds for which participants were divided into three groups: ≤300 hospital beds, 301–500 hospital beds, and >500 hospital beds.

In all analyses, P<0.05 were considered statistically significant, and all tests were two-tailed. Additionally, the phi coefficient (φ) and r were calculated to determine effect size (ES) for each difference. φ and r were defined as 0.10 for small ES, 0.30 for medium ES, and 0.50 for large ES. All data cleaning and analysis were performed using EZR (Saitama Medical Center, Jichi Medical University), which is a graphical user interface for R (The R Foundation for Statistical Computing).

RESULTS

Participant Characteristics

A total of 111 questionnaires were returned (response rate, 26.0%) of which the final sample comprised 104 participants (effective response rate, 24.2%). The characteristics of the participants are shown in Table 1. Their mean age was 45.4 years (standard deviation [SD], 5.8 years), and their mean nursing experience was 22.9 years (SD, 6.2 years). Males were younger than females (P<0.01, ES [r]=0.42). More than 70% of the nurses had >10 years of experience in emergency nursing. Both years of nursing and emergency nursing experience were shorter for males than for females, with P<0.01 (ES [r]=0.56) and 0.05 (ES [r]=0.21), respectively. Nearly half of the participants (51.9%) worked in hospitals with ≤500 beds.

Table 1.

Demographic and institutional characteristics

Experience of Caring for VVAW

More than 60% of the nurses had experience with caring for VVAW (Table 2). The mean number of VVAW cared for was 6.2; no significant difference was observed based on the nurse's gender (P=0.52, ES [r]=0.09).

Table 2.

The status of experience for caring for VAW victims and the number of VAW victims cared for (N=104)

Psychological Preparedness to Care for VVAW

The status of psychological preparedness to care for VVAW and differences according to the nurse's gender are presented in Table 3. Males had a higher mean score than females (P=0.03, ES [r]=0.22). Additionally, nurses with experience of caring for VVAW had a higher mean score than those without experience (P<0.01, ES [r]=0.33). Female nurses scored lower than male nurses across all items.

Table 3.

Difference in the psychological preparedness according to the nurses’ gender (N=104)

Institutional Support Systems

Less than half of participants reported institutional support (Table 4). “I can readily look up information, e.g., either a guide or standard operating procedure on how to manage cases of intimate partner violence or sexual violence," showed a significant difference according to the number of hospital beds (P<0.01, ES [φ]=0.43).

Table 4.

Difference between institutional support systems and number of hospital beds (N=104)

DISCUSSION

The three key findings of this study were: (1) approximately 60% of emergency nurses had provided care for VVAW without having received specific training; (2) male nurses scored higher than female nurses in terms of psychological preparedness with no differences in experience in caring for VVAW, the number of victims cared for, or their education concerning VAW; and (3) institutional support systems were inadequate regardless of the number of hospital beds.

While previous studies reported approximately 30%–60% of emergency nurses received education concerning abuse and violence [33,34], only 10% of emergency nurses received educational training in this study. Thus, the lack of education on caring for VVAW is evident in Japanese emergency nursing. Therefore, several victims may be overlooked. Previous studies have indicated that approximately 20% of victims of sexual assault exhibit no injuries [35,36] resulting in the under-recognition of the number of VVAW [37]. However, Aboutanos et al. [38] reported the role of awareness campaigns and educational training opportunities in improving victim recognition. Thus, the development of an educational program for emergency nursing that addresses the care of VAW in Japan is considered crucial. Addressing VAW requires a comprehensive approach encompassing legal, social, medical, and psychological perspectives [39]. Therefore, establishing a multifaceted educational program that includes both classroom lectures and simulations, e.g., virtual reality, in Japan may be considered effective [17,40,41].

Male nurses had higher psychological preparedness for caring for VVAW than female nurses in this study. Moreover, female nurses scored lower than male nurses for all items concerning psychological preparedness. In general, males are likely to feel more competent than females [42]. This trend extends to the medical environment in which male clinicians exhibit higher self-efficacy and confidence compared to female clinicians [43,44]. This supports the results of the present study. Moreover, Mphephu and du Plessis [45] reported that female nurses felt empathy for women experiencing gender-based violence. Therefore, female nurses in this study may have perceived the severity of VAW owing to their gender, thereby feeling psychologically unprepared. Further investigation is warranted to explore the association between gender and nurses' perceptions and understanding of VAW, as well as their psychological status.

Institutional support systems for care for VVAW were insufficient in Japanese EDs. Modifying the hospital structure, such as providing private examination rooms in which nurses can listen to VVAW, is currently not considered feasible. Additionally, overcrowding at EDs and nurse staffing shortages are challenging issues [46,47], and increasing the number of nurses is currently not possible. Rahmqvist et al. [48] reported that emergency nurses find appropriate guidelines helpful in caring for VAW, suggesting that establishing a clear protocol outlining procedures for communicating with authorities, preserving evidence, and communicating with victims in each ED is a practical step to consider. Therefore, relevant academic societies should provide guidelines and other information on the standard of care for VAW. Moreover, perceived institutional support is associated with self-efficacy among emergency nurses [49]. This suggests that enhancing institutional support might improve emergency nurses' psychological preparedness for caring for VVAW. In addition, the knowledge of emergency nurses with regard to the care of VVAW could be enhanced if learning opportunities for VAW care were established within the institutions. Tom et al. [50] and Shields et al. [51] highlighted that a local support system in collaboration with governmental organizations is warranted. This potentially includes an established system that allows public health nurses to follow up with patients who have provided their consent and to attend regular meetings between ED staffs and government officials to review ongoing care and collaboration.

This is the first nationwide study focused on VAW in Japanese EDs. However, our study has certain limitations. First, the participants are CENs who have specialized training regarding emergency nursing. Thus, the findings of the study do not fully represent the current state among emergency nurses in general. For example, psychological preparedness to care for VVAW may have lower scores; the scores on psychological preparedness for caring for VVAW of emergency nurses may be lower than those of CENs. Second, due to its cross-sectional nature, this study only reflects the status at a single point in time, and the criteria are not well understood. Furthermore, being a quantitative study, this study cannot reveal the emotional status of nurses, such as the feelings experienced by emergency nurses when caring for VVAW. Thus, the scope of the survey needs to be expanded, and regular surveys need to be conducted over time. Last, the questionnaire does not consider the characteristics of the victim, type of violence suffered, or severity of the violence, thereby limiting the results’ ability to reflect variation in nursing practices in different situations. Qualitative data, such as interview results, should be obtained to increase the comprehensive understanding of care for VVAW. Moreover, the perceptions and values of nurses working in EDs regarding issues such as gender roles and gender-based violence should be investigated.

KEY MESSAGES

▪ Despite more than 60% of emergency department (ED) nurses having experience caring for victims of violence against women (VVAW), only 10% received formal education or training on the topic; this highlights a critical gap in emergency nursing education in Japan.

▪ Female ED nurses exhibited lower psychological preparedness in caring for VVAW compared to male nurses.

▪ Nationwide organizational development, particularly concerning support systems, is vital for improving the quality of care of VVAW.

Notes

CONFLICT OF INTEREST

No potential conflict of interest relevant to this article was reported.

FUNDING

This research was supported by the research grant from the Japanese Association of Emergency Nursing (grant No. 062).

ACKNOWLEDGMENTS

I would like to express my sincerest gratitude to all the certified emergency nurses who participated in the study amidst the busy period of the COVID-19 pandemic.

AUTHOR CONTRIBUTIONS

All the work was done by AK.

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Variable	Total	Female	Male	P-value	ES
Sex	104	68 (65.4)	36 (34.6)
Age (yr)	45±6	47±6	43±5	<0.01	0.42
Nursing experience (yr)	22.9±6.2	25.1±6.0	18.6±3.9	<0.01	0.56
≤10	1 (1.0)
11–15	9 (8.7)
16–20	31 (29.8)
>20	63 (60.5)
Emergency nursing experience (yr)	13.9 (5.7)	14.7±5.9	12.4±5.0	0.05	0.21
≤10	30 (28.8)
11–15	32 (30.8)
16–20	23 (22.1)
>20	15 (14.4)
NA	4 (3.9)
Position		-	-	-	-
Staff nurse	63 (60.5)
Manager	27 (26.0)
Other	13 (12.5)
NA	1 (1.0)
Types of emergency department		-	-	-	-
Advanced Emergency department	12 (11.5)
Emergency department	32 (30.8)
Local emergency ward	25 (24.0)
Others	35 (33.7)
Number of hospital beds		-	-	-	-
≤300	23 (22.1)
301–500	31 (29.8)
>500	50 (48.1)
Previous education on caring for VAW victims		-	-	-	-
Yes	9 (8.7)
Watching educational video	2 (1.9)
Seminar	7 (6.7)
Workshop	0
No	95 (91.3)

	Total	Female	Male	P-value	ES
Experienced of caring for VAW victims				0.53	0.08^a)
Yes	63 (60.6)	43 (41.4)	20 (19.2)
No	41 (39.4)	25 (24.0)	16 (15.4)
Number of VAW victims cared	6.2±6.1	6.5±7.0	5.5±4.2	0.52	0.09^b)

	Total	Female	Male	P-value	ES
Psychological preparedness	21.1±5.62	20.4±6.15	22.6±4.15	0.03	0.22
Experienced caring for VAW victims				<0.01	0.33
Yes	22.4±5.52
No	19.0±5.17
Each item of psychological preparedness
Document the history and physical examination findings in the patient’s chart	2.95±0.85	2.83±0.90	3.17±0.70	0.04	0.21
Offer validating and supportive statements to a woman subjected to domestic or sexual violence	2.68±0.88	2.56±0.94	2.91±0.70	0.03	0.23
Talk to the woman about her needs and the options she may have	2.31±0.82	2.24±0.87	2.44±0.69	0.20	0.14
Ask a female patient about whether she has experienced intimate partner violence	2.31±0.80	2.28±0.84	2.36±0.72	0.61	0.06
Assess the immediate level of danger for a woman after sexual assault and/or intimate partner violence	2.28±0.86	2.16±0.91	2.50±0.74	0.04	0.22
Identify a woman who is or has been subjected to intimate partner violence by the signs and symptoms she reports	2.19±0.85	2.16±0.92	2.25±0.69	0.58	0.06
Provide care to a woman who is or has been subjected to intimate partner violence	2.12±0.83	2.00±0.88	2.33±0.68	0.03	0.22
Refer the woman to support services available within the community psychological, legal, shelter, etc.)	2.07±0.95	1.98±1.03	2.22±0.76	0.19	0.14
Help the woman create a plan to increase her and her children’s safety	1.97±0.90	1.79±0.91	2.30±0.79	<0.01	0.32

Institutional support systems	The number of hospital beds				P-value	ES
Institutional support systems	Total	≤ 300	301–500	>500	P-value	ES
I can readily look up information (e.g. either a guide or standard operating procedure on how to manage cases of intimate partner violence or sexual violence).	50 (48.1)	2 (1.9)	19 (18.3)	29 (27.9)	<0.01	0.43
I have a private space in the facility where I can talk to the woman confidentially about her abuse.	36 (34.6)	5 (4.8)	11 (10.6)	20 (19.2)	0.33	0.14
I have a colleague with whom I can get advice on how to respond to a difficult case of intimate partner violence if I do not know what to do.	28 (26.9)	6 (5.8)	8 (7.7)	14 (13.4)	1.00	0.01
My supervisor supports me pro-actively asking my patients or clients about whether they are experiencing intimate partner violence.	18 (17.4)	1 (1.0)	6 (5.8)	11 (10.6)	0.19	0.19